Medicaid Drives Expansion Of Health Care Coverage

As we all know, Obamacare is struggling with how to make the government online insurance exchanges work, which has diverted attention from another part of the Affordable Care Act which is being successfully implemented.

NPR's national political correspondent Mara Liasson reports.

MARA LIASSON, BYLINE: The Affordable Care Act is not just a website. It's not even just one thing. It's a set of regulations and mandates and subsidies that affect different people in different ways. It all adds up to big change in the healthcare system and right now one of the biggest changes is going almost unnoticed.

JONATHAN OBERLANDER: For the moment, Medicaid is the single biggest engine driving expansion of healthcare coverage in the United States

LIASSON: That's political scientist Jonathan Oberlander. In the first month of Obamacare, about 100,000 people signed up for private coverage through the exchanges. But about four times as many people got Medicaid. So right now Medicaid, the government-run single-payer part of Obamacare, is dwarfing private insurance enrollment.

OBERLANDER: What is ironic about that is Medicaid, of course, epitomizes government health insurance. And one of the arguments about the problems with the exchanges has been that this is an indictment of the government's ability to do anything. But the government program most associated with directly providing health insurance is succeeding much more so than the part of the part of the program that involves choosing from multiple private insurance plans.

LIASSON: Like everything else about Obamacare, the Medicaid expansion exists along a red/blue divide. Since the Supreme Court made the Medicaid expansion optional, most red states have refused it, but not all. At least 10 Republican governors decided to take the expansion. Here's Ohio Governor John Kasich making an argument that could've been made by Bill Clinton or Barack Obama.

GOVERNOR JOHN KASICH: I had a chance to bring Ohio money back to Ohio to make sure that the working poor have a system that makes sense instead of showing up and getting all their healthcare in emergency rooms.

LIASSON: Here's how the expansion works in another state, Arkansas. Before the Obamacare expansion, a family of three making just $2,500 a year in Arkansas made too much to get Medicaid. Now a family of three can make up to $27,000 and still qualify for the federal program. The White House has been trying to convince other Republican governors to allow more people to get Medicaid.

Jen Palmieri is President Obama's communication director.

JENNIFER PALMIERI: Big focus for us has been on the states that have chosen not to do Medicaid expansions and trying to get more attention there in those states to what kind of coverage people are missing out on.

LIASSON: President Obama has been taking this message on the road.

PRESIDENT BARACK OBAMA: Here in Louisiana that would benefit about 265,000 people. Here in just the Dallas area, 133,000 people who don't currently have health insurance would immediately get health insurance.

LIASSON: The federal government picks up almost all the cost of Medicaid expansion, but there's still been plenty of controversy. Many of the Republican governors who've taken it have had to fight their own Republican legislators. But that hasn't gotten as much attention for one big reason. Conservative writer Ramesh Ponnuru says Obamacare's opponents are focused on the problems of the new exchanges and the political damage they're causing to Democrats, which, he says, has been as compelling as a car crash.

RAMESH PONNURU: It's hard to avert your eyes from a massive pileup, and the exchange websites have proven so much more disastrous than even those of us who always criticized Obamacare had expected.

LIASSON: And there's another reason Medicaid expansion isn't in the crosshairs.

PETER WEHNER: Republicans are not going to do a frontal assault on something that people have come to accept.

LIASSON: Pete Wehner is a former policy aide to President George W. Bush.

WEHNER: I think it's perfectly fine if people want to go ahead and criticize Republican governors for agreeing to the expansion of Medicaid, but that is an issue in which the public has made their inner peace with just as they have with Social Security.

LIASSON: And that's really problematic for conservatives who think Medicaid is simply bad health insurance and an unwarranted expansion of the welfare state. Conservative columnist Ross Douthat says expansions of benefits like this are very hard to reverse, and by 2016 they'll be even harder.

ROSS DOUTHAT: At that point, Obamacare becomes part of the status quo and so any kind of Republican reform will have to push against that status quo. I think it's an open question at this point if a Republican president comes in in 2017 and there are millions more people on Medicaid thanks to the Obamacare expansion, is it possible to just roll that back without offering any kind of alternative reform?

LIASSON: Douthat says the answer is probably no, and that makes the Medicaid expansion a big challenge for Republicans. Ironically, it's the single-payer part of the Affordable Care Act providing free health coverage to millions of the working poor that might become the hardest to reverse, even if other parts of Obamacare continue to be unpopular. Mara Liasson, NPR News, the White House. Transcript provided by NPR, Copyright NPR.